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White SJ, Nguyen AD, Roger P, Tse T, Cartmill JA, Hatem S, Willcock SM. Tailoring communication practices to support effective delivery of telehealth in general practice. BMC PRIMARY CARE 2024; 25:232. [PMID: 38937674 PMCID: PMC11210157 DOI: 10.1186/s12875-024-02441-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 05/22/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND The unprecedented increase in telehealth use due to COVID-19 has changed general practitioners' (GP) and patients' engagement in healthcare. There is limited specific advice for effective communication when using telehealth. Examining telehealth use in practice in conjunction with perspectives on telehealth as they relate to communication allows opportunities to produce evidence-based guidance for optimal use of telehealth, while also offering practitioners the opportunity to reflect on elements of their communicative practice common to both styles of consultation. The objective of this research was to develop evidence-based resources to support effective, person-centred communication when GPs and patients use telehealth. This included examination of interactional practices of recorded telehealth consultations, exploration of GP and patient perspectives relating to telehealth, and identifying priorities for guidance informed by these analyses as well as participant co-design. METHODS This study involved recording telehealth consultations (n = 42), conducting patient surveys (n = 153), and interviewing patients (n = 9) and GPs (n = 15). These were examined using interaction analytic methods, quantitative analysis, and thematic analyses, to create a robust, integrated picture of telehealth practice and perspectives. The process of research translation involved a co-design approach, engaging with providers, patients, and policy makers to facilitate development of evidence-based principles that focus on supporting effective communication when using telehealth. RESULTS Three key themes relating to communication in telehealth were identified across the different analyses. These were relationship building, conversational flow, and safety netting. The draft best practice principles drawn from these themes were modified based on co-design feedback into five Best Practice Principles for Communication between GPs and Patients using Telehealth. CONCLUSIONS Effective communication is supported through relationship building and attention to conversational flow in telehealth consultations, which in turn allows for safety netting to occur. In telehealth, GPs and patients recognise that not being co-present changes the consultation and use both intuitive and strategic interactional adjustments to support their exchange. The mixed-method examination of experiences through both a detailed analysis of telehealth consultations in practice and comparative exploration of GP and patient perspectives enabled the identification of principles that can support effective communication when using telehealth. Co-design helped ensure these principles are ready for implementation into practice.
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Affiliation(s)
- Sarah J White
- Centre for Social Impact, UNSW Sydney, 704, Level 7, Science Engineering Building (E8), Kensington, NSW, 2052, Australia.
- Macquarie Medical School, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia.
| | - Amy D Nguyen
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia
- St Vincent's Clinical Campus, UNSW Sydney, Darlinghurst, NSW, Australia
| | - Peter Roger
- Department of Linguistics, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
| | - Tim Tse
- Department of Primary Care, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
| | - John A Cartmill
- Macquarie Medical School, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
| | - Sarah Hatem
- Department of Primary Care, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
| | - Simon M Willcock
- Department of Primary Care, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
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Rybczynska-Bunt S, Byng R, Spitters S, Shaw SE, Jameson B, Greenhalgh T. The reflexive imperative in the digital age: Using Archer's 'fractured reflexivity' to theorise widening inequities in UK general practice. SOCIOLOGY OF HEALTH & ILLNESS 2024. [PMID: 38922942 DOI: 10.1111/1467-9566.13811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 06/14/2024] [Indexed: 06/28/2024]
Abstract
'Reflexivity', as used by Margaret Archer, means creative self-mastery that enables individuals to evaluate their social situation and act purposively within it. People with complex health and social needs may be less able to reflect on their predicament and act to address it. Reflexivity is imperative in complex and changing social situations. The substantial widening of health inequities since the introduction of remote and digital modalities in health care has been well-documented but inadequately theorised. In this article, we use Archer's theory of fractured reflexivity to understand digital disparities in data from a 28-month longitudinal ethnographic study of 12 UK general practices and a sample of in-depth clinical cases from 'Deep End' practices serving highly deprived populations. Through four composite patient cases crafted to illustrate different dimensions of disadvantage, we show how adverse past experiences and structural inequities intersect with patients' reflexive capacity to self-advocate and act strategically. In some cases, staff were able to use creative workarounds to compensate for patients' fractured reflexivity, but such actions were limited by workforce capacity and staff awareness. Unless a more systematic safety net is introduced and resourced, people with complex needs are likely to remain multiply disadvantaged by remote and digital health care.
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Affiliation(s)
| | | | | | - Sara E Shaw
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Trisha Greenhalgh
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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McCann S, Entwistle VA, Oliver L, Lewis-Barned N, Haines R, Cribb A. Telephone consulting for 'Personalised Care and Support Planning' with people with long-term conditions: a qualitative study of healthcare professionals' experiences during COVID-19 restrictions and beyond. BMC PRIMARY CARE 2024; 25:193. [PMID: 38822282 PMCID: PMC11143770 DOI: 10.1186/s12875-024-02443-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 05/22/2024] [Indexed: 06/02/2024]
Abstract
BACKGROUND Personalised Care and Support Planning (PCSP) replaces conventional annual reviews for people with long-term conditions. It is designed to help healthcare professionals (HCPs) and patients engage in conversations as equals and collaboratively plan actions oriented to each patient's priorities, alongside biomedical concerns. Little is known about how the shift to remote consulting initiated with COVID-19 restrictions has impacted PCSP. AIM To investigate HCPs' experiences of conducting PCSP conversations remotely and consider implications for the fulfilment of PCSP ambitions as remote consulting continues beyond COVID-19 restrictions. METHODS 19 semi-structured interviews with HCPs in England and Scotland; interpretive analysis. RESULTS HCPs' accounts made clear that COVID-19 restrictions impacted multiple aspects of PCSP delivery, not just the mode of conversation. Broader disruption to general practice systems for gathering and sharing information ahead of PCSP conversations, and moves to 'wide window' appointment times, made it harder for patients to be prepared for PCSP conversations. This constrained scope to achieve PCSP ambitions even with the best professional communication skills. Most remote PCSP conversations were conducted by telephone. In the absence of visual communication with patients, it was sometimes harder to achieve the ambitions of PCSP conversations, including to balance patient and professional agendas, fulfil key planning activities, and foster a relational ethos of equal, collaborative partnership. The challenges were particularly severe when working with new patients and people with complex clinical and social problems. Although options for telephone appointments now offer valued flexibility, sustained experience of struggling to achieve PCSP ambitions via remote consulting led some HCPs to lower their standards for judging a "good" PCSP conversation, and to diminished professional satisfaction. CONCLUSIONS There are significant challenges to fulfilling the ambitions of PCSP via telephone, especially when preparatory support is limited. This study provides grounds for scepticism about how compatible telephone appointments can be with this person-centred model of working, especially for people who are socially disadvantaged and live with complex health conditions. These threats to the provision of person-centred support for people with long-term conditions warrant careful attention going forward if the PCSP model and its benefits are to be sustained.
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Affiliation(s)
- Sharon McCann
- Health Services Research Unit, University of Aberdeen, Aberdeen, AB25 2ZD, Scotland, UK.
| | - Vikki A Entwistle
- Health Services Research Unit, University of Aberdeen, Aberdeen, AB25 2ZD, Scotland, UK
- School of Divinity, History, Philosophy and Art History, University of Aberdeen, Aberdeen, Scotland, UK
| | - Lindsay Oliver
- Year of Care Partnerships, Northumbria Healthcare NHS Foundation Trust, Ashington, Northumberland, UK
| | - Nick Lewis-Barned
- Year of Care Partnerships, Northumbria Healthcare NHS Foundation Trust, Ashington, Northumberland, UK
| | | | - Alan Cribb
- Centre for Public Policy Research, King's College London, London, UK
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Anderson H, Scantlebury A, Galdas P, Adamson J. Remote and technology-mediated working during the COVID-19 pandemic: A qualitative exploration of the experiences of nurses working in general practice (the GenCo Study). J Adv Nurs 2024; 80:1592-1606. [PMID: 37909600 DOI: 10.1111/jan.15921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 10/12/2023] [Accepted: 10/15/2023] [Indexed: 11/03/2023]
Abstract
AIM To explore how nurses working in general practice experienced remote and technology-mediated working during the COVID-19 pandemic. DESIGN Exploratory qualitative study with nursing team members working in general practices in England and national nurse leaders. METHODS Data were collected between April and August 2022. Forty participants took part in either semi-structured interviews or focus groups. Data were analysed using Framework Analysis informed by the PERCS (Planning and Evaluating Remote Consultation Services) Framework. University of York ethics approval [HSRGC/2021/458/I] and Health Research Authority approval were obtained [IRAS:30353. Protocol number: R23982. Ref 21/HRA/5132. CPMS: 51834]. The study was funded by The General Nursing Council for England and Wales Trust. RESULTS Participants continued to deliver a significant proportion of patient care in-person. However, remote and technology-mediated care could meet patients' needs and broaden access in some circumstances. When remote and technology-mediated working were used this was often part of a blended model which was expected to continue. This could support some workforce issues, but also increase workload. Participants did not always have access to remote technology and were not involved in decision-making about what was used and how this was implemented. They rarely used video consultations, which were not seen to add value in comparison to telephone consultations. Some participants expressed concern that care had become more transactional than therapeutic and there were potential safety risks. CONCLUSION The study explored how nurses working in general practice during the COVID-19 pandemic engaged with remote and technology-mediated working. It identifies specific issues of access to technology, workload, hybrid working, disruption to therapeutic relationships, safety risks and lack of involvement in decision-making. Changes were implemented quickly with little strategic input from nurses. There is now an opportunity to reflect and build on what has been learned in relation to remote and technology-mediated working to ensure the future development of safe and effective nursing care in general practice. IMPACT The paper contributes to understanding of remote and technology-mediated working by nurses working in general practice during the COVID-19 pandemic and indicates to employers and policy makers how this can be supported moving forward. REPORTING METHOD Standards for Reporting Qualitative Research (O'Brien et al., 2014). PATIENT OR PUBLIC CONTRIBUTION This was a workforce study so there was no patient or public contribution. IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE The paper highlights specific issues which have implications for the development of remote, technology-mediated and blended working for nurses in general practice, care quality and patient safety. These require full attention to ensure the future development of safe and effective nursing care in general practice moving forward.
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Affiliation(s)
- Helen Anderson
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | | | - Paul Galdas
- Department of Health Sciences, University of York, York, UK
| | - Joy Adamson
- York Trials Unit, Department of Health Sciences, University of York, York, UK
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Cockburn L, Baer G, Rhodes J. Level of diagnostic agreement in musculoskeletal shoulder diagnosis between remote and face-to-face consultations: A retrospective service evaluation. Health Sci Rep 2024; 7:e2060. [PMID: 38650721 PMCID: PMC11033340 DOI: 10.1002/hsr2.2060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 03/22/2024] [Accepted: 04/03/2024] [Indexed: 04/25/2024] Open
Abstract
Background and Aims To determine the level of diagnostic agreement between remote and face-to-face consultation in assessing shoulder complaints. Methods A retrospective service evaluation with three groups of patient data; those assessed only face-to-face (group 1), remotely then face-to-face (group 2), remotely only (group 3). Patient data were extracted from 6 secondary care shoulder Advanced Physiotherapy Practitioner's (APPs) records, covering six sites. Three-hundred-and-fifty-nine sets of patient data were included in the final evaluation. The main outcome measure was the percentage of agreement between diagnosis at initial and follow-up consultation, when assessed by APPs across the three groups. A Pearson χ 2 test was used to assess the relationship between the method of consultation and the level of diagnostic agreement. Diagnoses were categorized as either the same, similar, or different by an independent APP. Secondary outcome measures investigated whether age or the length of time between appointments had any effect in determining the level of diagnostic concordance. Results There was exact agreement of 77.05% and 85.52% for groups 1 and 3, respectively, compared with 34.93% for patient data in group 2. Similar clinical impressions across both initial and follow-up were seen 16.39% of the time in group 1, 7.24% of the time in group 3, and 36.99% in group 2. Lastly, the percentage of times a diagnosis was changed between initial and review appointments occurred in only 6.56% of group 1 contacts, 7.24% of group 3 contacts, but 28.08% of the time in group 2. Conclusion There was a large mismatch in the diagnosis of musculoskeletal shoulder complaints, when patients are initially assessed remotely and then followed-up in-person. This has implications for the future provision of shoulder assessment in physiotherapy.
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Affiliation(s)
- Louise Cockburn
- Division of Dietetics Nutrition Biological Sciences Physiotherapy Podiatry and RadiographyQueen Margaret UniversityMusselburghUK
| | - Gill Baer
- Division of Dietetics Nutrition Biological Sciences Physiotherapy Podiatry and RadiographyQueen Margaret UniversityMusselburghUK
| | - Jenna Rhodes
- Division of Dietetics Nutrition Biological Sciences Physiotherapy Podiatry and RadiographyQueen Margaret UniversityMusselburghUK
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Moore L, Hughes G, Wherton J, Shaw S. 'When the visible body is no longer the seer': The phenomenology of perception and the clinical gaze in video consultations. SOCIOLOGY OF HEALTH & ILLNESS 2024; 46:418-436. [PMID: 37746806 DOI: 10.1111/1467-9566.13714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 08/11/2023] [Indexed: 09/26/2023]
Abstract
Video technology enabled professionals and patients to conduct consultations during the COVID-19 pandemic when in-person health care was minimised to reduce the spread of the virus. We present findings of a study of video-consulting through in-depth qualitative remote interviews with 40 health professionals, managers, support staff and 10 patients in health-care services across the UK from 2020 to 2021. Drawing on Foucault's concept of the clinical gaze, Merleau-Ponty's work on the phenomenology of perception and Ihde's postphenomenology we interpreted the ways in which remote consultations shaped patient-professional interactions, mediating and framing what was seen, revealed and known. We found that participating in video consultations not only involved creative adaption and adjustment to a virtual clinic but also changed how professionals and patients saw and were seen. We argue that this mode of consulting can transform boundaries and perceptions, alter aspects of clinical presence, knowledge and embodiment and thus both change and incorporate the clinical gaze.
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Affiliation(s)
- Lucy Moore
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Gemma Hughes
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- School of Business, University of Leicester, Leicester, UK
| | - Joseph Wherton
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sara Shaw
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Duffy SW, de Jonge L, Duffy TE. Effects on Cancer Prevention from the COVID-19 Pandemic. Annu Rev Med 2024; 75:1-11. [PMID: 37625124 DOI: 10.1146/annurev-med-051022-122257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/27/2023]
Abstract
The COVID-19 pandemic led to disruption of health services around the world, including cancer services. We carried out a narrative review of the effect of the pandemic on cancer prevention services, including screening. Services were severely affected in the early months of the pandemic, and in some areas are still recovering. Large numbers of additional cancers or additional late-stage cancers have been predicted to arise over the coming years as a result of this disruption. To minimize the effects on cancer outcomes, it is necessary to return as quickly as possible to prepandemic levels of screening and prevention activity or indeed to exceed these levels. The recovery of services should address health inequalities.
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Affiliation(s)
- Stephen W Duffy
- Centre for Prevention, Detection and Diagnosis, Wolfson Institute of Population Health, Queen Mary University of London, London, United Kingdom;
| | - Lucie de Jonge
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands;
| | - Thomas E Duffy
- Centre for Evaluation and Methods, Wolfson Institute of Population Health, Queen Mary University of London, London, United Kingdom;
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Payne R, Dakin F. The place of remote consultation in modern general practice. Br J Gen Pract 2024; 74:7-8. [PMID: 38154925 PMCID: PMC10755988 DOI: 10.3399/bjgp24x735873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2023] Open
Affiliation(s)
- Rebecca Payne
- National Institute for Health and Care Research In-Practice Fellow, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - Francesca Dakin
- Student and Research Assistant, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
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Payne R, Clarke A, Swann N, van Dael J, Brenman N, Rosen R, Mackridge A, Moore L, Kalin A, Ladds E, Hemmings N, Rybczynska-Bunt S, Faulkner S, Hanson I, Spitters S, Wieringa S, Dakin FH, Shaw SE, Wherton J, Byng R, Husain L, Greenhalgh T. Patient safety in remote primary care encounters: multimethod qualitative study combining Safety I and Safety II analysis. BMJ Qual Saf 2023:bmjqs-2023-016674. [PMID: 38050161 DOI: 10.1136/bmjqs-2023-016674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 10/31/2023] [Indexed: 12/06/2023]
Abstract
BACKGROUND Triage and clinical consultations increasingly occur remotely. We aimed to learn why safety incidents occur in remote encounters and how to prevent them. SETTING AND SAMPLE UK primary care. 95 safety incidents (complaints, settled indemnity claims and reports) involving remote interactions. Separately, 12 general practices followed 2021-2023. METHODS Multimethod qualitative study. We explored causes of real safety incidents retrospectively ('Safety I' analysis). In a prospective longitudinal study, we used interviews and ethnographic observation to produce individual, organisational and system-level explanations for why safety and near-miss incidents (rarely) occurred and why they did not occur more often ('Safety II' analysis). Data were analysed thematically. An interpretive synthesis of why safety incidents occur, and why they do not occur more often, was refined following member checking with safety experts and lived experience experts. RESULTS Safety incidents were characterised by inappropriate modality, poor rapport building, inadequate information gathering, limited clinical assessment, inappropriate pathway (eg, wrong algorithm) and inadequate attention to social circumstances. These resulted in missed, inaccurate or delayed diagnoses, underestimation of severity or urgency, delayed referral, incorrect or delayed treatment, poor safety netting and inadequate follow-up. Patients with complex pre-existing conditions, cardiac or abdominal emergencies, vague or generalised symptoms, safeguarding issues, failure to respond to previous treatment or difficulty communicating seemed especially vulnerable. General practices were facing resource constraints, understaffing and high demand. Triage and care pathways were complex, hard to navigate and involved multiple staff. In this context, patient safety often depended on individual staff taking initiative, speaking up or personalising solutions. CONCLUSION While safety incidents are extremely rare in remote primary care, deaths and serious harms have resulted. We offer suggestions for patient, staff and system-level mitigations.
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Affiliation(s)
- Rebecca Payne
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Aileen Clarke
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Nadia Swann
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jackie van Dael
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Natassia Brenman
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | | | - Lucy Moore
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Asli Kalin
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Emma Ladds
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | | | - Stuart Faulkner
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Isabel Hanson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sophie Spitters
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Sietse Wieringa
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Sustainable Health Unit, University of Oslo, Oslo, Norway
| | - Francesca H Dakin
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sara E Shaw
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Joseph Wherton
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Richard Byng
- Peninsula Schools of Medicine and Dentistry, University of Plymouth, Plymouth, UK
| | - Laiba Husain
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Trisha Greenhalgh
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Parry W, Fraser C, Crellin E, Hughes J, Vestesson E, Clarke GM. Continuity of care and consultation mode in general practice: a cross-sectional and longitudinal study using patient-level and practice-level data from before and during the COVID-19 pandemic in England. BMJ Open 2023; 13:e075152. [PMID: 37968008 PMCID: PMC10660661 DOI: 10.1136/bmjopen-2023-075152] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 10/16/2023] [Indexed: 11/17/2023] Open
Abstract
OBJECTIVES Investigate trends in continuity of care with a general practitioner (GP) before and during the COVID-19 pandemic. Identify whether continuity of care is associated with consultation mode, controlling for other patient and practice characteristics. DESIGN Retrospective cross-sectional and longitudinal observational studies. SETTING Primary care records from 389 general practices participating in Clinical Practice Research Datalink Aurum in England. PARTICIPANTS In the descriptive analysis, 100 000+ patients were included each month between April 2018 and April 2021. Modelling of the association between continuity of care and consultation mode focused on 153 475 and 125 298 patients in index months of February 2020 (before the pandemic) and February 2021 (during the pandemic) respectively, and 76 281 patients in both index months. PRIMARY AND SECONDARY OUTCOMES MEASURES The primary outcome measure was the Usual Provider of Care index. Secondary outcomes included the Bice-Boxerman index and count of consultations with the most frequently seen GP. RESULTS Continuity of care was gradually declining before the pandemic but stabilised during it. There were consistent demographic, socioeconomic and regional differences in continuity of care. An average of 23% of consultations were delivered remotely in the year to February 2020 compared with 76% in February 2021. We found little evidence consultation mode was associated with continuity at the patient level, controlling for a range of covariates. In contrast, patient characteristics and practice-level supply and demand were associated with continuity. CONCLUSIONS We set out to examine the association of consultation mode with continuity of care but found that GP supply and patient demand were much more important. To improve continuity for patients, primary care capacity needs to increase. This requires sufficient, long-term investment in clinicians, staff, facilities and digital infrastructure. General practice also needs to transform ways of working to ensure continuity for those that need it, even in a capacity-constrained environment.
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Affiliation(s)
| | | | | | - Jay Hughes
- Data Analytics, The Health Foundation, London EC4Y 8AP, UK
| | - Emma Vestesson
- Data Analytics, The Health Foundation, London EC4Y 8AP, UK
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Vestesson E, De Corte K, Chappell P, Crellin E, Clarke GM. Antibiotic prescribing in remote versus face-to-face consultations for acute respiratory infections in primary care in England: an observational study using target maximum likelihood estimation. EClinicalMedicine 2023; 64:102245. [PMID: 37842171 PMCID: PMC10568332 DOI: 10.1016/j.eclinm.2023.102245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 08/28/2023] [Accepted: 09/13/2023] [Indexed: 10/17/2023] Open
Abstract
Background The COVID-19 pandemic has led to an ongoing increase in the use of remote consultations in general practice in England. Although the evidence is limited, there are concerns that the increase in remote consultations could lead to more antibiotic prescribing. Methods In this cohort study, we used patient-level primary care data from the Clinical Practice Research Datalink to estimate the association between consultation mode (remote versus face-to-face) and antibiotic prescribing in England for acute respiratory infections (ARI) between April 2021 and March 2022. Eligibility criteria were applied at both practice-level and patient-level. 400 practices in England were sampled at random and then 600,000 patients were randomly sampled from the eligible patients (whose sex was recorded). Consultations for acute respiratory infections were identified. All antibiotic prescriptions were included, with the exception of antituberculosis drugs and antileprotic drugs, as identified through chapter 5.1 of the British National Formulary. The CPRD Aurum data was linked to the COVID-19 ONS infection survey by region. All analyses were done at the individual level. Repeated consultations from the same patient within 7 days were grouped together. We used targeted maximum likelihood estimation, a causal machine learning method with adjustment for infection type and patient-level, clinician-level and practice-level factors. Findings There were 45,997 ARI consultations (34,555 unique patients) within the study period, of which 28,127 were remote and 17,870 were face-to-face. For children, 48% of consultations were remote and, for adults, 66% were remote. For children, 42% of remote and 43% of face-to-face consultations led to an antibiotic prescription; the equivalent values for adults were 52% and 42%, respectively. After adjustment with TMLE, adults with a remote consultation had 23% (odds ratio [OR] 1.23, 95% CI: 1.18-1.29) higher chance of being prescribed antibiotics than if they had been seen face-to-face. We found no significant association between consultation mode and antibiotic prescribing in children (OR 1.04 95% CI: 0.98-1.11). Interpretation The higher rates of antibiotic prescribing in remote consultations for adults are cause for concern. We see no significant difference in antibiotic prescribing between consultation mode for children. These findings should inform antimicrobial stewardship activities for health-care professionals and policy makers. Future research should examine differences in guideline-compliance between remote and face-to-face consultations to understand the factors driving antibiotic prescribing in different consultation modes. Funding None.
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Affiliation(s)
- Emma Vestesson
- The Health Foundation, London, UK
- University College London Great Ormond Street Institute of Child Health, London, UK
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Ladds E, Greenhalgh T, Byng R, Rybczynska-Bunt S, Kalin A, Shaw S. A contemporary ontology of continuity in general practice: Capturing its multiple essences in a digital age. Soc Sci Med 2023; 332:116112. [PMID: 37535988 DOI: 10.1016/j.socscimed.2023.116112] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 07/14/2023] [Accepted: 07/20/2023] [Indexed: 08/05/2023]
Abstract
Continuity is a long-established and fiercely-defended value in primary care. Traditional continuity, based on a one-to-one doctor-patient relationship, has declined in recent years. Contemporary general practice is organisationally and technically complex, with multiple staff roles and technologies supporting patient access (e.g. electronic and telephone triage) and clinical encounters (e.g. telephone, video and electronic consultations). Re-evaluation of continuity's relational, organisational, socio-technical and professional characteristics is therefore timely. We developed theory in parallel with collecting and analysing data from case studies of 11 UK general practices followed from 2021 to 2023 as they introduced (or chose not to introduce) remote and digital services. We used strategic, immersive ethnography, interviews, and material analysis of technologies (e.g. digital walk-throughs). Continuity was almost universally valued but differently defined across practices. It was invariably situated and effortful, influenced by the locality, organisation, technical infrastructure, wider system and the values and ways of working of participating actors, and often requiring articulation and 'tinkering' by staff. Remote and digital modalities provided opportunities for extending continuity across time and space and for achieving-to a greater or lesser extent-continuity of digital records and shared understandings of a patient and illness episode across the clinical team. Delivering continuity for the most vulnerable patients was sometimes labour-intensive and required one-off adaptations. Building on earlier work by Haggerty et al. we propose a novel ontology of four analytically distinct but empirically overlapping kinds of continuity-of the therapeutic relationship (based on psychodynamic and narrative paradigms), of the illness episode (biomedical-interpretive paradigm), of distributed work (sociotechnical paradigm), and of the practice's commitment to a community (political economy and ethics of care paradigm). This ontology allowed us to theorise and critique successes (continuity achieved) and failures (breaches of continuity and fragmentation of care) in our dataset.
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Affiliation(s)
- Emma Ladds
- Nuffield Department of Primary Care Health Sciences, University of Oxford, UK.
| | - Trisha Greenhalgh
- Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
| | | | | | - Asli Kalin
- Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
| | - Sara Shaw
- Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
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Sidhu M, Walton H, Crellin N, Ellins J, Herlitz L, Litchfield I, Massou E, Tomini SM, Vindrola-Padros C, Fulop NJ. Staff experiences of training and delivery of remote home monitoring services for patients diagnosed with COVID-19 in England: A mixed-methods study. J Health Serv Res Policy 2023:13558196231172586. [PMID: 37366220 PMCID: PMC10300624 DOI: 10.1177/13558196231172586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2023]
Abstract
OBJECTIVES Remote home monitoring services for patients at risk of rapid deterioration introduced during the COVID-19 pandemic had important implications for the health workforce. This study explored the nature of 'work' that health care staff in England undertook to manage patients with COVID-19 remotely, how they were supported to deliver these new services, and the factors that influenced delivery of COVID-19 remote home monitoring services for staff. METHODS We conducted a rapid mixed-methods evaluation of COVID-19 remote home monitoring services during November 2020 to July 2021 using a cross-sectional survey of a purposive sample of staff involved in delivering the service (clinical leads, frontline delivery staff and those involved in data collection and management) from 28 sites across England. We also conducted interviews with 58 staff in a subsample of 17 sites. Data collection and analysis were carried out in parallel. We used thematic analysis to analyse qualitative data while quantitative survey data were analysed using descriptive statistics. RESULTS A total of 292 staff responded to the surveys (39% response rate). We found that prior experience of remote monitoring had some, albeit limited benefit for delivering similar services for patients diagnosed with COVID-19. Staff received a range of locally specific training and clinical oversight along with bespoke materials and resources. Staff reported feeling uncertain about using their own judgement and being reliant on seeking clinical oversight. The experience of transitioning from face-to-face to remote service delivery led some frontline delivery staff to reconsider their professional role, as well as their beliefs around their own capabilities. There was a general perception of staff being able to adapt, acquire new skills and knowledge and they demonstrated a commitment to continuity of care for patients, although there were reports of struggling with the increased accountability and responsibility attached to their adapted roles at times. CONCLUSIONS Remote home monitoring models can play an important role in managing a large number of patients for COVID-19 and possibly a range of other conditions. Successful delivery of such service models depends on staff competency and the nature of training received to facilitate effective care and patient engagement.
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Affiliation(s)
- Manbinder Sidhu
- Associate Professor, Health Services Management Centre, School of Social Policy, University of Birmingham, UK
| | - Holly Walton
- Research Fellow, Department of Applied Health Research, University College London, UK
| | | | - Jo Ellins
- Senior Fellow, Health Services Management Centre, School of Social Policy, University of Birmingham, UK
| | - Lauren Herlitz
- Research Fellow, Population, Policy and Practice, Great Ormond Street Institute of Child Health, University College London, UK
| | - Ian Litchfield
- Senior Research Fellow, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, UK
| | - Efthalia Massou
- Research Associate, Department of Public Health and Primary Care, University of Cambridge, UK
| | - Sonila M Tomini
- Assistant Professor, Global Business School for Health, University College London, UK
| | - Cecilia Vindrola-Padros
- Professorial Research Fellow, Department of Targeted Intervention, University College London, UK
| | - Naomi J Fulop
- Professor of Health Care Organisation and Management, Department of Applied Health Research, University College London, UK
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Rijpkema C, Bos N, Brandenbarg D, Homburg M, Beugel G, Barkema WS, Olde Hartman T, Muris J, Peters L, Berger M, Verheij RA, Ramerman L. What can we learn from experiences in general practice during the COVID-19 pandemic? A qualitative study. BMC Health Serv Res 2023; 23:696. [PMID: 37370101 DOI: 10.1186/s12913-023-09654-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 06/06/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Experiences with organizational changes in daytime general practices and out-of-hours (OOH) services during the COVID-19 pandemic may help to address the challenges in general practice care that were already a concern before the crisis. This study aimed to describe these experiences and the potential usefulness of the organizational changes for future general practice care and any future pandemics. METHODS Semi-structured interviews were performed among 11 directors of OOH services, and 19 (locum) general practitioners (GPs) or practice managers, who were purposively sampled. Video or telephone interviews were performed in two rounds: between November 2020 and January 2021 and between May 2021 and August 2021. The data were analyzed using thematic analysis methods. RESULTS Three themes emerged from the data: (1) Changes in the triage procedures; in GP practices and OOH services, stricter triage criteria were implemented, and GPs were more actively involved in the triage process. These measures helped to reduce the number of 'low urgency' face-to-face consultations. (2) Changes in GP care; there was a shift towards video and telephone consultations, allowing GPs to spend more time with patients during the remaining face-to-face consultations. For chronic patients, the shift towards telemonitoring appeared to encourage self-care, and postponing face-to-face consultations for regular checkups appeared to be unproblematic for stable patients. (3) Coordination of GP care and information communication flow during the COVID-19 pandemic; OOH directors perceived a lack of consistency in the information from various governmental and non-governmental parties on containment measures and guidelines related to COVID-19, making it difficult to act on them. The COVID-19 pandemic intensified collaboration between GPs, OOH services, and other healthcare professionals. CONCLUSIONS The results of this study indicate that some of the organizational changes, such as stricter triage, remote consultations, and changes in managed care of chronic patients, may help in tackling the pre-existing challenges in GP care from before the COVID-19 pandemic. However, more extensive research and continuous monitoring are necessary to establish the effects on patients and their health outcomes. To navigate future pandemics, the intensified collaboration between health professionals should be maintained, while there is considerable room for improvement in the provision of unambiguous information.
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Affiliation(s)
- Corinne Rijpkema
- Netherlands Institute for Health Services Research, Nivel, Utrecht, The Netherlands.
- Tilburg School of Social and Behavioral Sciences, Tilburg University, Tranzo, Tilburg, The Netherlands.
| | - Nanne Bos
- Netherlands Institute for Health Services Research, Nivel, Utrecht, The Netherlands
| | - Daan Brandenbarg
- Department of Primary and Long-term Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Maarten Homburg
- Department of Primary and Long-term Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Gina Beugel
- Department of Primary and Long-term Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Wietske S Barkema
- Department of Primary and Long-term Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Midwifery Science, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, AVAG, Amsterdam Public Health, Amsterdam, The Netherlands
| | - Tim Olde Hartman
- Department of Primary and Community Care, Radboud University Nijmegen Medical Center, Radboud Institute for Medical Innovation, Nijmegen, The Netherlands
| | - Jean Muris
- Department of Family Medicine, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Lilian Peters
- Department of Primary and Long-term Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Midwifery Science, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, AVAG, Amsterdam Public Health, Amsterdam, The Netherlands
| | - Marjolein Berger
- Department of Primary and Long-term Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Robert A Verheij
- Netherlands Institute for Health Services Research, Nivel, Utrecht, The Netherlands
- Tilburg School of Social and Behavioral Sciences, Tilburg University, Tranzo, Tilburg, The Netherlands
| | - Lotte Ramerman
- Netherlands Institute for Health Services Research, Nivel, Utrecht, The Netherlands
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15
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Vestesson EM, De Corte KLA, Crellin E, Ledger J, Bakhai M, Clarke GM. Consultation Rate and Mode by Deprivation in English General Practice From 2018 to 2022: Population-Based Study. JMIR Public Health Surveill 2023; 9:e44944. [PMID: 37129943 DOI: 10.2196/44944] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 02/03/2023] [Accepted: 03/14/2023] [Indexed: 05/03/2023] Open
Abstract
BACKGROUND The COVID-19 pandemic has had a significant impact on primary care service delivery with an increased use of remote consultations. With general practice delivering record numbers of appointments and rising concerns around access, funding, and staffing in the UK National Health Service, we assessed contemporary trends in consultation rate and modes (ie, face-to-face versus remote). OBJECTIVE This paper describes trends in consultation rates in general practice in England for key demographics before and during the COVID-19 pandemic. We explore the use of remote and face-to-face consultations with regard to socioeconomic deprivation to understand the possible effect of changes in consultation modes on health inequalities. METHODS We did a retrospective analysis of 9,429,919 consultations by general practitioners, nurses, or other health care professionals between March 2018 and February 2022 for patients registered at 397 general practices in England. We used routine electronic health records from Clinical Practice Research Datalink Aurum with linkage to national data sets. Negative binomial models were used to predict consultation rates and modes (ie, remote versus face-to-face) by age, sex, and socioeconomic deprivation over time. RESULTS Overall consultation rates increased by 15% from 4.92 in 2018-2019 to 5.66 in 2021-2022 with some fluctuation during the start of the COVID-19 pandemic. The breakdown into face-to-face and remote consultations shows that the pandemic precipitated a rapid increase in remote consultations across all groups, but the extent varies by age. Consultation rates increased with increasing levels of deprivation. Socioeconomic differences in consultation rates, adjusted for sex and age, halved during the pandemic (from 0.36 to 0.18, indicating more consultations in the most deprived), effectively narrowing relative differences between deprivation quintiles. This trend remains when stratified by sex, but the difference across deprivation quintiles is smaller for men. The most deprived saw a relatively larger increase in remote and decrease in face-to-face consultation rates compared to the least deprived. CONCLUSIONS The substantial increases in consultation rates observed in this study imply an increased pressure on general practice. The narrowing of consultation rates between deprivation quintiles is cause for concern, given ample evidence that health needs are greater in more deprived areas.
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Affiliation(s)
- Emma Maria Vestesson
- The Health Foundation, London, United Kingdom
- Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | | | | | - Jean Ledger
- National Health Service England, London, United Kingdom
| | - Minal Bakhai
- National Health Service England, London, United Kingdom
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Rijpkema C, Ramerman L, Homburg M, Meijer E, Muris J, Olde Hartman T, Berger M, Peters L, Verheij R. Care by general practitioners for patients with asthma or COPD during the COVID-19 pandemic. NPJ Prim Care Respir Med 2023; 33:15. [PMID: 37031214 PMCID: PMC10082338 DOI: 10.1038/s41533-023-00340-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 03/23/2023] [Indexed: 04/10/2023] Open
Abstract
The impact of the COVID-19 pandemic on general practitioners' (GP) care for patients with asthma and/or COPD is largely unknown. To describe the impact of the pandemic on asthma or COPD-related GP care, we analysed routinely recorded electronic health records data from Dutch general practices and out-of-hours (OOH) services. During the COVID-19 pandemic (2020), the contact rates for asthma and/or COPD were significantly lower in GP practices and OOH services compared with the pre-pandemic period (2019) (respectively, 15% lower and 28% lower). The proportion of telephone contacts increased significantly with 13%-point in GP practices and 12%-point at OOH services, while the proportion of face-to-face contacts decreased. Furthermore, the proportion of high urgent contacts with OOH services decreased by 8.5%-point. To conclude, the overall contact rates in GP practices and OOH services decreased, while more contacts were remote. Lower contact rates have, after a short follow-up, not resulted in more patients with exacerbations in OOH care. However, this might still be expected after a longer follow-up.
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Affiliation(s)
- Corinne Rijpkema
- Nivel, Netherlands Institute for Health Services Research, Utrecht, The Netherlands.
- Tilburg School of Social and Behavioural Sciences, Tilburg University, Tilburg, The Netherlands.
| | - Lotte Ramerman
- Nivel, Netherlands Institute for Health Services Research, Utrecht, The Netherlands
| | - Maarten Homburg
- Department of General Practice and Elderly Care Medicine, UMCG, University Medical Centre Groningen, Groningen, The Netherlands
| | - Eline Meijer
- Department of General Practice and Elderly Care Medicine, UMCG, University Medical Centre Groningen, Groningen, The Netherlands
- Data Science Centre in Health (DASH), UMCG, University Medical Centre Groningen, Groningen, The Netherlands
| | - Jean Muris
- Department of Family Medicine, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Tim Olde Hartman
- Radboud Institute of Health Sciences, Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Marjolein Berger
- Department of General Practice and Elderly Care Medicine, UMCG, University Medical Centre Groningen, Groningen, The Netherlands
| | - Lilian Peters
- Department of General Practice and Elderly Care Medicine, UMCG, University Medical Centre Groningen, Groningen, The Netherlands
- Vrije Universiteit Amsterdam, Midwifery Science, AVAG, Amsterdam Public Health, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Robert Verheij
- Nivel, Netherlands Institute for Health Services Research, Utrecht, The Netherlands
- Tilburg School of Social and Behavioural Sciences, Tilburg University, Tilburg, The Netherlands
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Hughes G, Rybczynska-Bunt S, Shasha'h S, Greene S, Shaw S, Greenhalgh T. Protocol: How can people with social care needs be supported through processes of digital care navigation to access remote primary care? A multi-site case study in UK general practice of remote care as the 'new normal'. NIHR OPEN RESEARCH 2023; 3:17. [PMID: 37881454 PMCID: PMC10593327 DOI: 10.3310/nihropenres.13385.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/01/2023] [Indexed: 10/27/2023]
Abstract
Background Care navigation refers to support for patients accessing primary care and other related services. The expansion of digitally enabled care in the UK since the coronavirus disease 2019 (COVID-19) pandemic has led to a greater need for digital care navigation: supporting people to access primary care digitally and, if necessary, to help them find alternative non-digital routes of access. Support to patients with social care needs (including but not limited to those who are homeless and insecurely housed, living in residential care and supported by domiciliary carers) increasingly involves work to navigate primary care provided remotely and accessed digitally. There is little knowledge about how this work is being done. Methods Care Navigation involves embedded researchers identifying digital care navigation for patients accessing services in 11 GP practices recruited to a linked study of remote primary care ( Remote care as the 'new normal?'). Digital care navigation will be studied through go-along (in-person or remote) interviews with a sample of 20 people offering formal (paid or voluntary) support, 6 national and regional stakeholders who plan, commission or provide digital care navigation and a focus group with 12 social prescribers engaged in digital care navigation. A co-design workshop with people working in, or commissioning, social care settings will consider how findings can inform improved digital care navigation, for example through the development of resources or guidance for care navigators. Results anticipated Findings are anticipated to include evidence of how digital care navigation is practised, the work that is done to support patients in accessing remote primary care, and how this work is shaped by material resources and variations in the configuration of services and infrastructure. Conclusions New explanations of the work needed to navigate digital care will inform policy and service developments aimed at helping patients benefit from remote primary care.
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Affiliation(s)
- Gemma Hughes
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Sarah Rybczynska-Bunt
- Penisula Medical School (Faculty of Health), University of Plymouth, Plymouth, PL6 8BX, UK
| | - Sara Shasha'h
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Sarah Greene
- Penisula Medical School (Faculty of Health), University of Plymouth, Plymouth, PL6 8BX, UK
| | - Sara Shaw
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Trisha Greenhalgh
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
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Norberg BL, Getz LO, Johnsen TM, Austad B, Zanaboni P. General Practitioners' Experiences With Potentials and Pitfalls of Video Consultations in Norway During the COVID-19 Lockdown: Qualitative Analysis of Free-Text Survey Answers. J Med Internet Res 2023; 25:e45812. [PMID: 36939814 PMCID: PMC10131921 DOI: 10.2196/45812] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 02/22/2023] [Accepted: 02/26/2023] [Indexed: 03/21/2023] Open
Abstract
BACKGROUND The use of video consultations (VCs) in Norwegian general practice rapidly increased during the COVID-19 pandemic. During societal lockdowns, VCs were used for nearly all types of clinical problems, as in-person consultations were kept to a minimum. OBJECTIVE This study aimed to explore general practitioners' (GPs') experiences of potentials and pitfalls associated with the use of VCs during the first pandemic lockdown. METHODS Between April 14 and May 3, 2020, all regular Norwegian GPs (N=4858) were invited to answer a web-based survey, which included open-ended questions about their experiences with the advantages and pitfalls of VCs. A total of 2558 free-text answers were provided by 657 of the 1237 GPs who participated in the survey. The material was subjected to reflexive thematic analysis. RESULTS Four main themes were identified. First, VCs are described as being particularly convenient, informative, and effective for consultations with previously known patients. Second, strategically planned VCs may facilitate effective tailoring of clinical trajectories that optimize clinical workflow. VCs allow for an initial overview of the problem (triage), follow-up evaluation after an in-person consultation, provision of advice and information concerning test results and discharge notes, extension of sick leaves, and delivery of other medical certificates. VCs may, in certain situations, enhance the GPs' insight in their patients' relational and socioeconomical resources and vulnerabilities, and even facilitate relationship-building with patients in need of care who might otherwise be reluctant to seek help. Third, VCs are characterized by a demarcated communication style and the "one problem approach," which may entail effectiveness in the short run. However, the web-based communication climate implies degradation of valuable nonverbal signals that are more evidently present in in-person consultations. Finally, overreliance on VCs may, in a longer perspective, undermine the establishment and maintenance of relational trust, with a negative impact on the quality of care and patient safety. Compensatory mechanisms include clarifying with the patient what the next step is, answering any questions and giving further advice on treatment if conditions do not improve or there is a need for follow-up. Participation of family members can also be helpful to improve reciprocal understanding and safety. CONCLUSIONS The findings have relevance for future implementation of VCs and deserve further exploration under less stressful circumstances.
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Affiliation(s)
- Børge Lønnebakke Norberg
- General Practice Research Unit, Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
- Norwegian Centre for E-health Research, Tromsø, Norway
| | - Linn Okkenhaug Getz
- General Practice Research Unit, Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | | | - Bjarne Austad
- General Practice Research Unit, Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
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Kristiansen E, Atherton H, Austad B, Bergmo T, Norberg BL, Zanaboni P. Older patients' experiences of access to and use of e-consultations with the general practitioner in Norway: an interview study. Scand J Prim Health Care 2023; 41:33-42. [PMID: 36592342 PMCID: PMC10088919 DOI: 10.1080/02813432.2022.2161307] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE To explore older patients' experiences with accessing and using e-consultations to send text-based clinical inquiries to the general practitioner (GP) online. DESIGN Qualitative study based on semi-structured interviews. Results were analysed through a six-phase thematic analysis and interpreted through Levesque's framework of patient-centred access to health care. SETTING General practice in Norway. SUBJECTS Patients aged over 65 years (n = 16) with experience in using e-consultations. RESULTS Respondents considered e-consultations as an integrated part of general practice which helped them achieve better access to health care. We identified four themes describing older patients' access to and use of e-consultations: 1) the importance of digital health literacy to learn about and use the service - and the fear of losing it, 2) the high availability of the service as the main advantage, due to the perceived unavailability of physical GP services, 3) the importance of voluntary use of e-consultations, 4) the importance of a trusting relationship with the GP. IMPLICATIONS Information about e-consultations and guidelines for suitable use are recommended to ensure equal access to all patients, regardless of their digital health literacy. Availability problems and high work burdens for the GPs could affect the patients' choice for using e-consultations. If e-consultations are used for triage purposes, caution should be taken to avoid a shift in workload from the health secretary to the GP.Key points of articleThe extended use of e-consultations with the general practitioner has raised concerns that the service may not be accessible and suitable for older patients.For older users, e-consultations can represent a positive addition to physical consultation forms due to the high availability of the service in a general practice setting characterised by long waiting times.Digital health literacy is essential to learn about and use the service. Information about the service and how to use it should be available to all patients to ensure equal access.A trusting relationship with the GP is described as essential for older patients to perceive the outcome of e-consultations as appropriate and safe.
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Affiliation(s)
- Eli Kristiansen
- Norwegian Centre for E-health Research, University Hospital of North Norway, Tromsø, Norway
- Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - Helen Atherton
- Unit of Academic Primary Care, Warwick Medical School, UK
| | - Bjarne Austad
- General Practice Research Unit, Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Trine Bergmo
- Norwegian Centre for E-health Research, University Hospital of North Norway, Tromsø, Norway
| | - Børge Lønnebakke Norberg
- Norwegian Centre for E-health Research, University Hospital of North Norway, Tromsø, Norway
- General Practice Research Unit, Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Paolo Zanaboni
- Norwegian Centre for E-health Research, University Hospital of North Norway, Tromsø, Norway
- Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
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Muacevic A, Adler JR. The Impact of COVID-19 on Primary Care: A Scoping Review. Cureus 2023; 15:e33241. [PMID: 36618499 PMCID: PMC9815485 DOI: 10.7759/cureus.33241] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/29/2022] [Indexed: 01/04/2023] Open
Abstract
The COVID-19 pandemic had a severe impact on various aspects of everyday life, including healthcare provision. The aim of the scoping review was to collate, summarize, and discuss this literature, in light of the impact COVID-19 had on Primary care. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) four-stage process framework for reporting was followed. A total of 31 studies were included in this review. Based upon our review we found COVID-19 pandemic on Primary Care, has made significant effects on 1) service redesign, 2) long-term illness care provision, 3) healthcare staff well-being and 4) the post-pandemic future of Primary Care. The COVID-19 outbreak has demonstrated, how a pandemic can drastically change the process of healthcare provision within the community, as evidenced by the change in consultation styles with patients, the impact on the physical and mental wellbeing of health workers, a shift from isolated practice to teamwork, as well as the ability of healthcare workers to seek prompt help with their health. Studies have demonstrated progress in knowledge and experience gained by healthcare workers when tackling COVID-19, and how these can be implemented in possible future pandemics affecting Primary Care, however, further research is required within this sphere.
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Pickard Strange M, Booth A, Akiki M, Wieringa S, Shaw SE. The role of virtual consulting in developing environmentally sustainable healthcare: a systematic literature review (Preprint). J Med Internet Res 2022; 25:e44823. [PMID: 37133914 DOI: 10.2196/44823] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 03/29/2023] [Accepted: 03/31/2023] [Indexed: 04/03/2023] Open
Abstract
BACKGROUND Health systems globally need to rapidly set and achieve targets for reaching net zero carbon emissions. Virtual consulting (including video- and telephone-based consulting) is regarded as one means by which this might be achieved, largely through reduced patient travel. Little is currently known about the ways in which forms of virtual consulting might contribute to the net zero agenda or how countries may develop and implement programs at scale that can support increased environmental sustainability. OBJECTIVE In this paper, we asked, What is the impact of virtual consulting on environmental sustainability in health care? and What can we learn from current evaluations that can inform future reductions in carbon emissions? METHODS We conducted a systematic review of published literature according to PRISMA (Preferred Reporting Item for Systematic Reviews and Meta-Analyses) guidelines. We searched the MEDLINE, PubMed, and Scopus databases using key terms relating to "carbon footprint," "environmental impact," "telemedicine," and "remote consulting," using citation tracking to identify additional articles. The articles were screened, and full texts that met the inclusion criteria were obtained. Data on the approach to carbon footprinting reported reductions in emissions, and the opportunities and challenges associated with the environmental sustainability of virtual consultations were extracted into a spreadsheet, analyzed thematically, and theorized using the Planning and Evaluating Remote Consultation Services framework to consider the various interacting influences, including environmental sustainability, that shape the adoption of virtual consulting services. RESULTS A total of 1672 papers were identified. After removing duplicates and screening for eligibility, 23 papers that focused on a range of virtual consulting equipment and platforms across different clinical conditions and services were included. The focus on the environmental sustainability potential of virtual consulting was unanimously reported through carbon savings achieved by a reduction in travel related to face-to-face appointments. The shortlisted papers used a range of methods and assumptions to determine carbon savings, reporting these using different units and across varied sample sizes. This limited the potential for comparison. Despite methodological inconsistencies, all papers concluded that virtual consulting significantly reduced carbon emissions. However, there was limited consideration of wider factors (eg, patient suitability, clinical indication, and organizational infrastructure) influencing the adoption, use, and spread of virtual consultations and the carbon footprint of the entire clinical pathway in which the virtual consultation was provided (eg, risk of missed diagnoses from virtual consultations that result in the need for subsequent in-person consultations or admissions). CONCLUSIONS There is overwhelming evidence that virtual consulting can reduce health care carbon emissions, largely through reducing travel related to in-person appointments. However, the current evidence fails to look at system factors associated with implementing virtual health care delivery and wider research into carbon emissions across the entire clinical pathway.
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Affiliation(s)
- Martha Pickard Strange
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Amy Booth
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Melissa Akiki
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Sietse Wieringa
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
- University of Oslo, Oslo, Norway
| | - Sara E Shaw
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
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Telehealth and primary care: a special collection from BJGP Open. BJGP Open 2022; 6:BJGPO.2022.0120. [PMID: 36028300 PMCID: PMC9904778 DOI: 10.3399/bjgpo.2022.0120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 08/18/2022] [Accepted: 08/23/2022] [Indexed: 10/31/2022] Open
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23
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Rosen R, Greenhalgh T. How can remote GP consultations be safer? BMJ : BRITISH MEDICAL JOURNAL 2022. [DOI: 10.1136/bmj.o2843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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